Healthcare Provider Details

I. General information

NPI: 1447751045
Provider Name (Legal Business Name): PAUL DOUGLAS HULSEBERG PA-C, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 JOHN Q HAMMONS DR
MADISON WI
53717-1921
US

IV. Provider business mailing address

514 DUNNING ST
MADISON WI
53704-5633
US

V. Phone/Fax

Practice location:
  • Phone: 608-251-4156
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4646-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: